DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public - be skeptical and don't follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.

Brief background. DSM 5 got off to a bad start and was never able to establish sure footing. Its leaders initially articulated a premature and unrealizable goal- to produce a paradigm shift in psychiatry. Excessive ambition combined with disorganized execution led inevitably to many ill conceived and risky proposals.

These were vigorously opposed. More than fifty mental health professional associations petitioned for an outside review of DSM 5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits. Professional journals, the press, and the public also weighed in- expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

DSM 5 has neither been able to self correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop- circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis. Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably 'psychosis risk', mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, 'hebephilia', cumbersome personality ratings, and sharply lowered thresholds for many existing disorders). But APA stubbornly refused to sponsor any independent review and has given final approval to the ten reckless and untested ideas that are summarized below.

The history of psychiatry is littered with fad diagnoses that in retrospect did far more harm than good. Yesterday's APA approval makes it likely that DSM 5 will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society.

The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their's is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

The APA's deep dependence on the publishing profits generated by the DSM 5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM 5 public trust and DSM 5 as a best seller. When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM 5 field testing step that was meant to provide it with a badly needed opportunity for quality control. The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only- so that DSM 5 publishing profits can fill the big hole in APA's projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM 5 preparation.

This is no way to prepare or to approve a diagnostic system. Psychiatric diagnosis has become too important in selecting treatments, determining eligibility for benefits and services, allocating resources, guiding legal judgments, creating stigma, and influencing personal expectations to be left in the hands of an APA that has proven itself incapable of producing a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs- often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

So, here is my list of DSM 5's ten most potentially harmful changes. I would suggest that clinicians not follow these at all (or, at the very least, use them with extreme caution and attention to their risks); that potential patients be deeply skeptical, especially if the proposed diagnosis is being used as a rationale for prescribing medication for you or for your child; and that payers question whether some of these are suitable for reimbursement. My goal is to minimize the harm that may otherwise be done by unnecessary obedience to unwise and arbitrary DSM 5 decisions.

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhoodBipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this 'condition' (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sexaddiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new 'patients' and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment. This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM's teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and 'behavioral addictions' will soon be mislabeled as psychiatrically sick and given inappropriate treatment.

People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM 5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill.

Our patients deserve better, society deserves better, and the mental health professions deserve better. Caring for the mentally ill is a noble and effective profession. But we have to know our limits and stay within them.

DSM 5 violates the most sacred (and most frequently ignored) tenet in medicine- First Do No Harm! That's why this is such a sad moment.

You raise a good point re: financial conflicts of interest of the authors of the DSM-V when you say that "they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies", however I think that you overlook another important conflict of interest which ties the two together, which is the conflict of interest of power and influence.

In a nutshell, psychiatry is not viewed as a legitimate science and/or branch of medicine by many (and considering the actions of the DSM-V authors and APA why would it be?). Instead of actually testing their ideas and seeing if they hold true or not (which is admittedly hard to do when one is promoting unfalsifiable conjecture in the place of valid testable hypotheses), admitting failures when they occur and acknowledging the limitations of one's specialty (as the DSM-V authors/APA have repeatedly shown they have no interest in doing), one quick and possibly more direct way to acheive 'respectability' in this regard is to simply have colorful little pills to prescribe to people. By having such pills available to them (whether these colorful little pills work or not, a subject which is very much open to question when you consider the numerous problems which have been repeatedly documented on the subject of industry-sponsored 'research studies'), psychiatrists gain a semblence of legitimacy as to the fundamental worth and/or value of their profession. The more 'disorders' they have to 'treat' with their colorful little pills, the more 'legitimacy' they obtain as a result, with the relationship between the two growing in direct proportion to one another. This of course greatly benefits the pharmaceutical industry which makes vast sums of money as a result of selling these colorful little pills. The result of all this? DSM-V.

Although your cynicism towards our field is justified, I believe that your claims about the legitimacy of psychiatry, and the clinical research that backs it, they are purely misguided. I would somewhat agree on a profit-related incentive in the quasi psychopharmacology-corporate "conspiracy" (for the lack of a more appropriate term at the moment) that you speculate exists. Given that there might be skewed results presented by studies funded by the companies who make the drugs, drug efficacy and area of effect specificity has been on the rise and has been tested by non-interested third parties. Furthermore, most of the changes have been made in light of findings through neurobiological research that has been used more widely to provide a "more empirical" and "scientific way" of providing highly descriptive evidence for the etiology and course of illness of many psychiatric disorders, which in turn guides nosology, then treatment. The author's fear of a "slippery slope" for the creation of behavioral addiction category is also misguided since these addictions have proven to create similar neuroplasticity with people suffering with substance abuse, thus giving credence to their power. I agree with the sentiment behind his or her condemnation for BA's inclusion (a product of the [ironically] soritesean paradox of what is considered psychopathology, stigma, etc.), but one cannot question the existence (and the evidence for it) of most of the new classes of disorders that DSM V considers psychopathology nor the efficacy of the appropriate psychiatric medication used to alleviate the crippling acute symptoms of a disabling psychiatric illness. I could say more, but please please, practice prudence with informed reason

I agree, and am especially alarmed about Dr. Frances' title: "Ignore Its Ten Worst Changes." I could see "have caution" or "do some research and draw your own conclusions," but "ignore" is way too extreme (and irresponsible).

Beloveds,
the old is fading away and the New is already in Place.
In the new approach to all physical, mental and spiritual issues we use VIBRATIONAL MEDICINES. Those Vibrational Medicines have been tested in the Tribal- Shamanic- Tradition for thousands of years. Vibrational medicines include also new age techniques and highly advanced new technology.
All the solutions the pharmacological and medical establishment are offering right now will fade away, because the new methods will be much more effective than the old.
All the books who are considered bibles in the field are based on false asumptions that the body is a machine and that the spirit has nothing to do with the body/mind.
Ladies and Gentlemen we need to accept that also we are a part of the experiment: if you choose wisely which imput you give into creation the outcome will be beautiful for you and all the Universe and its creatures.
Blessings to all
George - centreoflight

Energy therapy - or vibrational medicine as George wrote - is the wave of the future. It provides an overview of a person and easily encompasses DSM distinctions, no matter what the vintage, without taking them as the end product of analysis. As Dr. Stolorow wrote elsewhere, one of the great shortcomings of any DSM approach is that it does not take into account the social field of the person, the interpersonal relationships and the social and political forces acting upon a person. Even more, the DSMs do not take into account the Soul, the Life Force, the Prana, of the person. Laugh if you like, but that is what heals -and shows respect for the client. Energy therapy can even include pharmacology, but does not rely on it, or any single intervention. Rather, the person's own energies are helped back into right relationship with themselves and their environment. What a pity that the small minded interests of the mental health guilds stigmatize even learning about energy medicine. Their refusal to look at something is hardly scientific, which is especially ironic since they pretentiously lay claim to being the only legitimate source of scientific knowledge.

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

Submitted by James DeCarli, MPH, MPA, MCHES on December 2, 2012 - 3:54pm

I am sorry that when I submitted this that it posted several times.

As I had mentioned that misdiagnosis of forgetting as labeled as Minor Neurocognitive Disorder, is a major concern among victims of Intimate Partner Violence (IPV) and those victims where perpetrators have personality disorders such as passive agressive personality disorder for example, and label and blame their victims. With Minor Neurocognitive Disorder, these perpetractors now will have professional support. Thus establishing these victims being now at risk of being misdiagnosed and treated for Minor Neurocognitive Disorder.

In addition, similarly to victims of elder abuse. Such a misdiagnosis will further provide evidence to a victim that they need to be medicated.

Both research communities in IPV and elder abuse should take note of this issue leading to many false positives, over medication, and increasing victimization in IPV and elder abuse.

I don't mind your repost, but I am very curious about the connection of IPV and Minor Neurocognitive Disorder. I've just never heard of this connection before. Could you explain the cause and effect here, or perhaps link to some literature on the subject? I'd appreciate it.

One link between IPV and Minor Neurocognitive Disorder: an uncertain but not insignificant proportion of victims/survivors of partner violence have (often undiagnosed) mild traumatic brain injury as a result of their abuse.

The OP's concern seems to be different: that abusive partners will convince doctors to misdiagnose 'normal' behaviour as psychological disorders, then force treat with medication (ie chemical restraint).

Thanks for this great article. I agree that intellectual conflicts of interest are a serious problem and that failure to field test is also a failure in the production of this manual.

Another new diagnosis which deserves to be on this list is the Somatic Disorders diagnosis. Under this diagnosis, if a person has symptoms which are currently unexplained (whether because they do not have a diagnosis or whether because they have symptoms not listed in their diagnostic description), they can be given this label.

The treatment is CBT to correct the patients' anxieties which are giving rise to these 'extra' symptoms. Worse, to not conduct further testing to see if there is an alternate diagnosis which is a better fit or whether there is a comorbid condition.

This is bogus because all diseases have patients with symptoms not in the official definitions. And it's dangerous because many patients originally receive one or several incorrect diagnoses.

It also is biased towards a view that unexplained symptoms are necessarily psychosomatic. We should maybe have learned something from figuring out that multiple sclerosis, epilepsy, and so on are not psychosomatic.

Any patient is able to get additional conditions. It is very dangerous to put patients in a "do not test further" category.

I'm not in favor of any treatment programs, but a large body of brain research exist that points to all addictions causing the same fundamental brain changes and being triggered by the same molecular switches (deltaFosb & CREB).

Eating to obesity has countless animaland human brain studies all revealing the same brain changes as occur in drug addicts. The animal studies reveal all the same molecular mechanisms & specific brain changes.

Unike the other 9 worst changes, or any of the other current DSM diagnosis, addiction is backed up by 30 years of research, and thousands of animal and human brain studies.

It's clear from his writings that Frances is woefully ignorant of the state of current addiction neuroscience. No wonder he wasn't involved this time around.

Thank you for your comment. I agree with quite a bit of Dr. Frances' article, but he does not seem to have kept up with the literature on behavioral addiction and related brain science. The criteria for addiction should be whether people are suffering and having adverse consequences in their lives--not the specific substance or activity. After all, alcohol is an "everyday" thing just like the Internet or TV or sex. Why should it be given any special status?

As someone who has struggled with both 'behavioral addictions' and substance abuse (both of which nearly killed me), I wonder if Dr. Frances has any concept of the similarity between the two processes from the patient's perspective (in addition to the neurological basis). There is already enough stigma and difficulty getting medical professionals to recognize that 'behavioral addictions' are serious conditions; it is distressing to me that a physician at my own institution has written something that may be used to further deny the struggle of these patients. I am now happily in recovery from all addictive processes, but I certainly have compassion for those still suffering.

I agree that the DSM-V is far from perfect, and I understand that sometimes you have to be controversial to get attention on these blogs. However, I'm very concerned that the extreme and one-sided perspective of Dr. Frances will end up hurting the exact patient population he is trying to protect. Additionally, family members are much more likely to read a blog like this than a scientific journal, and I'm worried that they could now cite a Duke Physician as supporting them in their deny of their loved ones 'behavioral addiction.'

Dr. Frances makes a good point, it is up to use, as "front-line" clinicians to exercise our own judgement when deciding on whether or not to use a particular diagnosis. There is absolutely no legal or ethical requirement for us to label any individual with a diagnosis, if doing so would be contrary to our clinical opinion. If you are upset about these upcoming changes, remember that we, as clinicians, are the last line of defense!!

I wholeheartedly agree. The DSM IV TR or 5 are just guides to know what type of treatment or counseling technique to use. We are studying the DSM IV TR in Psychopathology in a Clinical Perspective at Walden.

Dr. Frances,
Thank you for your insights into the DSM process, which I've always found enlightening.

I have the same question for you that I've put to other researchers and clinicians, including some of those engaged in the DSM-5 autism revisions (with no answer so far): why are you so sure that autism/Asperger's is overdiagnosed? Over the last year we've seen frequent references to this "overdiagnosis" problem, but no supporting data. The increasing prevalence does not in itself justify this conclusion. What does?

Gluttony is a judgment word, not a diagnosis or especially compassionate. I am doing an undergraduate study on obesity bias. Sir, your attitude towards binge eating is not helpful in treating or finding compassion for the stigmatized obese population.

Research shows that binge eating is very often connected to adverse childhood experiences (see the CDC's ACE Study), much in the way of many self-destructive behaviors. Yes, there is sensual pleasure in a gluttonous feast, but binge eaters have usually gone long past the point of pleasure in their eating and do it strictly to manage anxiety. Treat the anxiety and the binge eating tends to take care of itself. As it is currently, most insurance companies refuse treatment of eating disorders apart from anorexia and bulimia with purging.

I would ask you kindly to reconsider using stigmatizing language with any population, not just the obese.

I agree with this comment. I am 20 years old, 5 feet tall, and 100 pounds, and I have binge-eating disorder. The state of public information about eating disorders frustrates me. Excessive eating as an expression of gluttony is not a psychological disorder, but when overeating becomes a coping mechanism for unresolved internal conflicts, binge-eating disorder can result. This article made very good points, but the undermining of a legitimate psychological addiction is an insensitive and ignorant shame.

I too am glad that Binge Eating Disorder finally made the cut, and that Dr. Frances' comments about "gluttony" are inappropriate. We are not talking about people who eat too much on Thanksgiving here. We are talking about people with a very real emotional and physiological complex that need help and need to be taken seriously.

I too am so relieved to see comments here that are also dismayed at Mr. Frances' judgments of BED. I had never heard of BED until early 2012 and was so relieved when I finally found a name for my experience. Until then, I could not understand why I couldn't lose weight. I became a regular exerciser. I know EVERYTHING about nutrition. I know every method to lose weight yet no matter what, I could not stop sabotaging myself. I cannot express the relief and - oh, the validation! - I felt when I heard this was going to be included in DSM5. There is no question in my mind I have disordered eating and this is it. Now that I have the name I can work on a proper solution using the write tools, which are psychological in nature and actually have nothing to do with what I put in my mouth. I have found support groups, books, and am starting a cognitive therapy program. Thank you, Ms. Mendoza for your comments. What I wouldn't give to be able to live completely without food, it would be so much easier for me that way. Contrary to what my body seems to suggest, I do not love food. Far from it - I hate food. But eating sugary crap numbs an underlying anxiety, sadness, and anger that creep up under my skin and in my heart before I am really conscious that they are there. My journey now is to make those feelings conscious and figure out what the eff to do with them. Now that I have a name and a pathway to healing what has been buried for soo long under "emotional eating" and "just eat less and exercise more,"or "losing weight is so difficult," I can finally begin to heal my life and my soul. And maybe one day, when I tell loved ones about my disorder, they won't look at me like a pathetic fat chick looking for an excuse for why she's fat as they have up until now.

The attempt to categorise psychological symptoms into discrete diagnoses is never going to be without problems, but I too was disturbed to read the glib dismissal of a serious problem as nothing more than a moral failing. As noted by previous commenters, there is nothing pleasurable about pathological binge eating, and the behaviour is a physical manifestation of serious underlying problems. Would you consider anorexia nervosa simply 'picky eating'?

Absolutely not. While Bulimia involves the consumption of large amounts of food, the person feels so much self-disgust that they attempt to compensate for the binge by purging, restricting, exercising, or laxatives. Gluttony itself does not influence such negative feelings. "Gluttony" is neither an eating disorder nor a classification; it is simply a word that means "eating to excess." Indulging at buffets occasionally is gluttonous--normal but gluttonous. There is nothing wrong with being a glutton now and then, we all do it. It is a problem, however, when the excessive eating is used to compensate for overwhelming emotions and when it becomes an uncontrollable force in one's life. Labeling an eating disorder binge (whether BED or Bulimia) as gluttonous is ignorant because it oversimplifies how complex eating disorders really are. AAAhhh its so frustrating that DSM criterion places so much emphasis on the eating habits rather than their underlying causes universal to all eating disorders.

Absolutely not. While Bulimia involves the consumption of large amounts of food, the person feels so much self-disgust that they attempt to compensate for the binge by purging, restricting, exercising, or laxatives. Gluttony itself does not influence such negative feelings. "Gluttony" is neither an eating disorder nor a classification; it is simply a word that means "eating to excess." Indulging at buffets occasionally is gluttonous--normal but gluttonous. There is nothing wrong with being a glutton now and then, we all do it. It is a problem, however, when the excessive eating is used to compensate for overwhelming emotions and when it becomes an uncontrollable force in one's life. Labeling an eating disorder binge (whether BED or Bulimia) as gluttonous is ignorant because it oversimplifies how complex eating disorders really are. AAAhhh its so frustrating that DSM criterion places so much emphasis on the eating habits rather than their underlying causes universal to all eating disorders.

Absolutely not. While Bulimia involves the consumption of large amounts of food, the person feels so much self-disgust that they attempt to compensate for the binge by purging, restricting, exercising, or laxatives. Gluttony itself does not influence such negative feelings. "Gluttony" is neither an eating disorder nor a classification; it is simply a word that means "eating to excess." Indulging at buffets occasionally is gluttonous--normal but gluttonous. There is nothing wrong with being a glutton now and then, we all do it. It is a problem, however, when the excessive eating is used to compensate for overwhelming emotions and when it becomes an uncontrollable force in one's life. Labeling an eating disorder binge (whether BED or Bulimia) as gluttonous is ignorant because it oversimplifies how complex eating disorders really are. AAAhhh its so frustrating that DSM criterion places so much emphasis on the eating habits rather than their underlying causes universal to all eating disorders.

Absolutely not. While Bulimia involves the consumption of large amounts of food, the person feels so much self-disgust that they attempt to compensate for the binge by purging, restricting, exercising, or laxatives. Gluttony itself does not influence such negative feelings. "Gluttony" is neither an eating disorder nor a classification; it is simply a word that means "eating to excess." Indulging at buffets occasionally is gluttonous--normal but gluttonous. There is nothing wrong with being a glutton now and then, we all do it. It is a problem, however, when the excessive eating is used to compensate for overwhelming emotions and when it becomes an uncontrollable force in one's life. Labeling an eating disorder binge (whether BED or Bulimia) as gluttonous is ignorant because it oversimplifies how complex eating disorders really are. AAAhhh its so frustrating that DSM criterion places so much emphasis on the eating habits rather than their underlying causes universal to all eating disorders.

Absolutely not. While Bulimia involves the consumption of large amounts of food, the person feels so much self-disgust that they attempt to compensate for the binge by purging, restricting, exercising, or laxatives. Gluttony itself does not influence such negative feelings. "Gluttony" is neither an eating disorder nor a classification; it is simply a word that means "eating to excess." Indulging at buffets occasionally is gluttonous--normal but gluttonous. There is nothing wrong with being a glutton now and then, we all do it. It is a problem, however, when the excessive eating is used to compensate for overwhelming emotions and when it becomes an uncontrollable force in one's life. Labeling an eating disorder binge (whether BED or Bulimia) as gluttonous is ignorant because it oversimplifies how complex eating disorders really are. AAAhhh its so frustrating that DSM criterion places so much emphasis on the eating habits rather than their underlying causes universal to all eating disorders.

Absolutely not. While Bulimia involves the consumption of large amounts of food, the person feels so much self-disgust that they attempt to compensate for the binge by purging, restricting, exercising, or laxatives. Gluttony itself does not influence such negative feelings. "Gluttony" is neither an eating disorder nor a classification; it is simply a word that means "eating to excess." Indulging at buffets occasionally is gluttonous--normal but gluttonous. There is nothing wrong with being a glutton now and then, we all do it. It is a problem, however, when the excessive eating is used to compensate for overwhelming emotions and when it becomes an uncontrollable force in one's life. Labeling an eating disorder binge (whether BED or Bulimia) as gluttonous is ignorant because it oversimplifies how complex eating disorders really are. AAAhhh its so frustrating that DSM criterion places so much emphasis on the eating habits rather than their underlying causes universal to all eating disorders.

Interesting article. The thing that interests me most is Dr. Frances' view on Binge Eating Disorder. Maybe the criteria make little sense (12 times in 3 months, or roughly once a week, but who can really put a number on it?), but to call it simple gluttony when people are indeed suffering terribly from it seems ignorant to me. Other posts have made clear the cause and effects of the suffering. The major difference between a binger and a bulimic is the absence of purging. In my case, (being open here) I'm a Type 1 diabetic, and I "purge" by not taking insulin, but so far as I know, by the criteria of DSM-IV, I'm not bulimic. OK, so I can omit insulin and not gain weight, or even lose weight, but what about the people who binge and don't purge and still suffer miserably, and quite possibly gain a lot of weight? Are they just simple gluttons, or is there, in fact, a psychological disorder behind their bingeing?

A contributor to the problem of conflict of interest in psychiatry is that psychiatrists strongly prefer medication to behavior modification, cognitive-behavioral (or other) therapy, motivational interviewing, lifestyle modifications such as exercise, meditation and other mindfulness practices, and other non-pharmacological methods. The rush to write a prescription is a big part of the reason psychiatry is losing its credibility, in my opinion. It seems like a cop-out, and is riddled with potential for financial and other conflicts of interest. I think the point that not all conflict of interest is financial is an important one; this is also about power, prestige and influence.

I think for all of the reasons offered, the APA's role as the sole author of the primary Diagnostic manual for mental health issues should be reevaluated. The APA wrote the original DSM because no other mental health professionals were willing to do so, but that has changed. I believe that the role of the DSM in diagnosis and reimbursement, and the introduction of so many other scientifically informed clinicians into the field, indicates that the primary diagnostic manual used in the United States should be an interdisciplinary, collaborate effort that includes Psychologists, counselors, social workers, and other mental health care providers in addition to the APA. The APA's resistance to the inclusion of outside input from these other practioners, and their refusal to address many of the concerns inherent in this version of the DSM, suggest that the APA is no longer suitable to be the primary organization producing this document. Perhaps if the task of producing the primary diagnostic manual in the United States were taken away from the APA, psychiatrists would be able to better address the conflicts of interest that have led to this document, and could offer their own unique wisdom in a manner more conducive to producing a document that is more productive than those used previously.

It's intellectually weak and socially dangerous to imply a new mental disorder is proven by any kind of brain imaging study. It's incorrect causation, and it's also a category error. A simple example: let's say that thinking about sports, or thinking about red, or thinking about sex, all create distinct brain imaging patterns that differ from a resting state. Can we conclude from this that any of these things are (or are not), mental disorders? No, not at all.

This misuse of neuroscience by psychology is a classic case of an immature science grasping for explanations provided by the available tools. This is also seen in the biosciences, where massive overemphasis is placed on the search for genetic factors, simply because we have DNA sequencing, but way out of proportion to the predictive and diagnostic value of genetic sequencing.

If a mental disorder can be proven on clinical grounds, and then also show to have a brain imaging correlate, that might be helpful for diagnosis. But it is foolishness to create a new category of mental disorder on this basis.

I will be entering the field of psychology after completing my masters degree. I already have issues with the DSM-IV because I feel it does not allow for "isolated incidents" or reasonable belief that behavior is temporary or attributable to learning something that can be un-learned." I am saddened to know that the newest mental illnesses will further subjugate us to the mercy of what medication is available for our "problem".